Basic Information
| Provider Information | |||||||||
| NPI: | 1801876040 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARYOTT | ||||||||
| FirstName: | DWAYNE | ||||||||
| MiddleName: | BRIAN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1840 W ARLINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278345704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524136202 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1850 W ARLINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278345704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524136202 | ||||||||
| FaxNumber: | 2527588333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2006 | ||||||||
| LastUpdateDate: | 05/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-01043 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | MA001621L | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 004628-1 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 8102826 | 05 | NC | MEDICAID |